Georgia Workers Comp Insurance

Start the application process with the form below… We provide workers comp quotes once the online application is submitted.

NOTE: WE NOW HAVE Pay-As-You-Go Workers Comp Insurance Solutions

Application-General Data

1. Business Name
2. Type of Business Please Choose Sole Proprietor Partnership LLC Corporation S-Corp Non-Profit Joint Venture Religious Org Professional Assoc Governmental Entity Trust
3. Your Name(required)
4. Email(valid email required)
5. Website
6. Phone Number(required)
7. Years in Business
8. Street Address
9. City
10. State
11. Zip(required)
12. States You Do Business In
13. Federal Tax ID number or Social

Mulitiple Locations

1. List Addressses of all company locations:

Policy Info

1. Proposed Effective Date
2. States to be included in coverage
3. Preferred Coverage Amount 100,000/500,000/100,000 500,000/500,000/500,000 1mil/1mil/1mil

Rating Information

1. Workers Comp rates the policy based on the what the worker does. Breaking out each classs of worker ensures the proper rating on a per class basis. Example: Clarical Office Staff - 4 full time 2 part time payroll totaling x.xx.
2. Class of Worker
3. How Many Full and Part time
4. Estimated Yearly Payroll for this Class of worker
5. Class or Worker
6. How Many Full and Part time
7. Estimated Yearly Payroll for this Class of worker
8. Class of Worker
9. How Many Full and Part time
10. Estimated Yearly Payroll for this Class of worker
11. Class of Worker
12. How Many Full and Part time
13. Estimated Yearly Payroll for this Class of worker

Prior Carrier Loss History

1. Please list loss history from prior carrier.

Individuals to be included/excluded from coverage

1. Owner's Name (required)
2. Owner's Birthdate(required)
3. Owner's title Member Owner President Secretary Tresurer Vice-President (required)
4. % of Ownership(required)
5. Include or Exclude Exclude Include (required)
6. Estimated Payroll
7. Owner's Name
8. Owner's Birthdate
9. Owner's title Member Owner President Secretary Tresurer Vice-President
10. % of Ownership
11. Include or Exclude Exclude Include
12. Estimated Payroll
13. Owner's Name
14. Owner's Birthdate
15. Owner's title Member Owner President Secretary Tresurer Vice-President
16. % of Ownership
17. Include or Exclude Exclude Include
18. Estimated Payroll

Nature of Businsess

1. Describe Business
2. Enter Loss History:no loss history

General Informaiton

1. 1.DOES APPLICANT OWN, OPERATE, LEASE AIRCRAFT/WATERCRAFT?
2. Yes
   No
3. 2. DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATION INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL?
4. Yes
   No
6. Yes
   No
7. 3. ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET?
8. Yes
   No
9. 4. ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER?
10. Yes
    No
11. 5. IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS?
12. Yes
    No
13. 6. ARE SUB-CONTRACTORS USED?
14. Yes
    No
15. 7. ANY WORK SUBLET WITHOUT CERTIFICATES OF INSURANCE?
16. Yes
    No
17. 8. IS A WRITTEN SAFETY PROGRAM IN OPERATION?
18. Yes
    No
19. 9. ANY GROUP TRANSPORTATION PROVIDED?
20. Yes
    No
21. 10. ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE?
22. Yes
    No
23. 11. ANY SEASONAL EMPLOYEES?
24. Yes
    No
25. 12. IS THERE ANY VOLUNTEER OR DONATED LABOR?
26. Yes
    No
27. 13. ANY EMPLOYEES WITH PHYSICAL HANDICAPS?
28. Yes
    No
29. 14. DO EMPLOYEES TRAVEL OUT OF STATE?
30. Yes
    No
31. 15. ARE ATHLETIC TEAMS SPONSORED?
32. Yes
    No
33. 16. ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE?
34. Yes
    No
35. 17. ANY OTHER INSURANCE WITH THIS INSURER?
36. Yes
    No
37. 18. ANY PRIOR COVERAGE DECLINE/CANCELLED/NON-RENEWED (Last 3 years)?
38. Yes
    No
39. 19. ARE EMPLOYEE HEALTH PLANS PROVIDED?
40. Yes
    No
41. 20. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS/SUBSIDIARY?
42. Yes
    No
43. 21. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?
44. Yes
    No
45. 22. DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME?
46. Yes
    No
47. 23. ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST 5 YEARS?
48. Yes
    No
49. 24. ANY UNDISPUTED AND UNPAID WORKERS COMPENSATION PREMIUM DUE FROM YOU
50. Yes
    No
51. Remarks

Validation

1. Ten minus five equals

 

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